Sensory changes after treatment of operable breast cancer

NaV1.7 targeted fluorescence imaging agents for nerve identification during intraoperative procedures

Surgeries and trauma result in traumatic and iatrogenic nerve damage that can result in a debilitating condition that approximately affects 189 million individuals worldwide. The risk of nerve injury during oncologic surgery is increased due to tumors displacing normal nerve location, blood turbidity, and past surgical procedures, which complicate even an experienced surgeon's ability to precisely locate vital nerves. Unfortunately, there is a glaring absence of contrast agents to assist surgeons in safeguarding vital nerves. To address this unmet clinical need, we leveraged the abundant expression of the voltage-gated sodium channel 1.7 (NaV1.7) as an intraoperative marker to access peripheral nerves in vivo, and visualized nerves for surgical guidance using a fluorescently-tagged version of a potent NaV1.7-targeted peptide, Tsp1a, derived from a Peruvian tarantula. We characterized the expression of NaV1.7 in sensory and motor peripheral nerves across mouse, primate, and human specimens and demonstrated universal expression. We synthesized and characterized a total of 10 fluorescently labeled Tsp1a-peptide conjugates to delineate nerves. We tested the ability of these peptide-conjugates to specifically accumulate in mouse nerves with a high signal-to-noise ratio in vivo. Using the best-performing candidate, Tsp1a-IR800, we performed thyroidectomies in non-human primates and demonstrated successful demarcation of the recurrent laryngeal and vagus nerves, which are commonly subjected to irreversible damage. The ability of Tsp1a to enhance nerve contrast during surgery provides opportunities to minimize nerve damage and revolutionize standards of care across various surgical specialties.

Ropivacaine continuous wound infusion after mastectomy with immediate autologous breast reconstruction: A retrospective observational study

Continuous wound infusion usually provides postoperative analgesia as a multimodal analgesia with systemic opioid use. When continuous wound infusion of local anesthetics (LA) supports successful postoperative analgesia without systemic opioid use, the side effects of opioid can be reduced. Nevertheless, continuous wound infusion after mastectomy with immediate autologous breast reconstruction leads to concerns about wound healing. This study evaluated analgesic effects and wound healing conditions of continuous wound infusion of LA compared with opioid-based, intravenous patient-controlled analgesia (IV PCA) in mastectomy with immediate autologous breast reconstruction.This retrospective observational study included females, aged between 33 and 67 years, who underwent mastectomy with immediate autologous breast reconstruction. Sixty-five patients were enrolled. The eligible patients were placed into 2 groups for managing postoperative pain, one used continuous wound infusion with 0.5% ropivacaine (ON-Q, n = 32) and the other used a fentanyl-based IV PCA (IV PCA, n = 33). Using the electronic medical record system, the postoperative recovery profiles were examined over 5 days using a visual analogue scale (VAS), incidence of postoperative nausea and vomiting (PONV), incidence of sleep disturbance, frequency of rescue analgesic use, analgesia-related adverse events, length of hospital stay, and degree of patient satisfaction. The condition of the surgical wound was observed for 1 year after surgery.The primary endpoint was the intensity of pain at 6 hours after surgery. The VAS was comparable between the groups (P > .05). Although recovery profiles and the degree of patient satisfaction were similar between the groups, the incidence of PONV was significantly lower in the ON-Q group than in the IV PCA group on the day of surgery and postoperative day 1. No patients had severe wound complications. The satisfaction score of analgesia in the ON-Q group was comparable with that of the patients in the IV PCA group.This study demonstrates that single use of continuous wound infusion showed comparable analgesia with fentanyl-based IV PCA in patients who underwent mastectomy with immediate autologous breast reconstruction. Furthermore, the continuous infusion of LA directly on the surgical site did not significantly affect wound healing.

Persistent breast pain following breast cancer surgery is associated with persistent sensory changes, pain interference, and functional impairments

Interindividual variability exists in persistent breast pain following breast cancer surgery. Recently, we used growth mixture modeling to identify 3 subgroups of women (N = 398) with distinct persistent breast pain trajectories (ie, mild, moderate, severe) over 6 months following surgery. The purposes of this study were to identify demographic and clinical characteristics that differed among the breast pain classes and, using linear mixed effects modeling, to examine how changes over time and in sensitivity in the breast scar area, pain qualities, pain interference, and hand and arm function differed among these classes. Several demographic and clinical characteristics differentiated the breast pain classes. Of note, 60 to 80% of breast scar sites tested were much less sensitive than the unaffected breast. Significant group effects were observed for pain qualities and interference scores, such that, on average, women in the severe pain class reported higher scores than women in the moderate pain class. In addition, women in the moderate pain class reported higher scores than women in the mild pain class. Compared to women in the mild pain class, women in the severe pain class had significantly impaired grip strength, and women in the moderate and severe pain classes had impaired flexion and abduction.

PERSPECTIVE

Subgroups of women with persistent postsurgical breast pain differed primarily with respect to the severity rather than the nature or underlying mechanisms of breast pain. Pervasive sensory loss and the association between persistent breast pain and sustained interference with function suggest the need for long-term clinical follow-up.

Persistent arm pain is distinct from persistent breast pain following breast cancer surgery

Persistent pain following breast cancer surgery is well documented. However, it is not well characterized in terms of the anatomic site affected (ie, breast, arm). In 2 separate growth mixture modeling analyses, we identified subgroups of women (N = 398) with distinct breast pain and arm pain trajectories. The fact that these latent classes differed by anatomic site, types of tissue affected, and neural innervation patterns suggests the need for separate evaluations of these distinct persistent pain conditions. The purposes of this companion study were to identify demographic and clinical characteristics that differed between the 2 arm pain classes and determine if differences existed over time in sensitivity in the upper inner arm and axillary lymph node dissection sites, pain qualities, pain interference, and hand and arm function, as well as to compare findings with persistent breast pain. Higher occurrence rates for depression and lymphedema were found in the moderate arm pain class. Regardless of pain group membership, sensory loss was observed in the upper inner arm and axillary lymph node dissection site. Arm pain was described similarly to neuropathic pain and interfered with daily functioning. Persistent arm pain was associated with sustained impairments in shoulder mobility.

PERSPECTIVE

For persistent breast and arm pain, changes in sensation following breast cancer surgery were notable. Persistent arm pain was associated with sustained interference with daily functioning and upper body mobility impairments. Long-term management of persistent pain following breast cancer surgery is warranted to improve the quality of survivorship for these women.

Bilateral prophylactic mastectomy in women with inherited risk of breast cancer--prevalence of pain and discomfort, impact on sexuality, quality of life and feelings of regret two years after surgery

BACKGROUND

Mastectomy due to breast cancer is associated with chronic pain and a negative impact on sexuality. The purposes of the study were to analyze the prevalence of pain and discomfort in the breasts, impact on sexuality, quality of life, and feelings of regret after bilateral prophylactic mastectomy and immediate reconstruction with implants.

METHODS

Fifty-nine women operated 2004-2006 were included. A questionnaire was sent out two years after the procedure. Complications and re-operations were recorded.

RESULTS

Mean follow-up time was 29 months. 93% of patients answered the questionnaire. 69% reported pain and 71% discomfort in the breasts. Lost or much reduced sexual sensations were reported by 85% and enjoyment of sex was negatively impacted for 75% of patients. Quality of life was not affected and feelings of regret were almost non-existent.

CONCLUSIONS

It is important to inform women approaching this prophylactic procedure about the risk of having unwanted secondary effects.

Burn after breast reconstruction

AIMS

Burns occur rarely after breast reconstruction, and results from loss of sensory and thermoregulatory skin functions. We aimed to investigate the pathophysiological processes leading to these injuries.

METHOD

Cases described in the literature are reviewed and discussed. Three cases of burn complicating the outcome of two implants and one autologous breast reconstruction are newly reported.

DISCUSSION

The ineffectiveness of skin thermoregulatory reflexes, caused by different surgical procedures, plays an essential role in the pathogenesis of burns to reconstructed breasts; tissue expansion and radiotherapy are also essential aetiological factors.

Depressive symptomatology correlates with phantom breast syndrome in mastectomized women

OBJECTIVE

Phantom breast syndrome (PBS) after mastectomy has been hypothesized to represent a complex psychological reaction to mastectomy, but psychological studies concerning PBS are few and inconclusive. This study aimed to assess possible correlations of PBS to current psychopathology and personality dimensions, as well as to examine subjectively experienced provoking and relieving factors for the experience of PBS.

METHOD

A total of 105 women who had undergone modified radical mastectomy were interviewed by a structured questionnaire after breast surgery. Moreover, they completed a set of self-administered psychometric scales consisting of Symptom Checklist-90-R, Eysenck personality questionnaire, Zung depression scale, State-Trait Anxiety Inventory and Whiteley Index of hypochondriasis.

RESULTS

PBS was experienced by 24 women (22.9%). The majority of them thought that PBS did not interfere with their everyday life. Women with PBS scored significantly higher on the Zung depression scale. Multiple logistic regression analysis revealed that women aged more than 66 years were 82% less likely to have PBS compared to those aged less than 51 years.

CONCLUSION

These findings provide evidence that PBS is associated with higher scores of depressive symptomatology and younger age. The nature of such an association remains unclear and calls for further investigation.

Pain and quality of life after surgery for breast cancer

BACKGROUND

In breast cancer (BC) patients, conservative surgery (CS) followed by irradiation or immediate breast reconstruction (IBR) after modified radical mastectomy (MRM) has been proposed in the attempt to avoid the negative impact of MRM on feminine body image. Regardless of the type of operation, BC patients may feel pain even without recurrent disease with poor adjustment in terms of quality of life (QL).

METHODS

We adopted a questionnaire comprising the short form of the McGill Pain questionnaire, and a previously validated questionnaire able to identify four subscales exploring physical well-being, physical autonomy, relational life and psychological well-being. The questionnaire was mailed in 1999 to a consecutive series of 757 (CS: 481 cases; MRM + IBR with skin expander: 93 cases; MRM: 183 cases) disease-free patients treated for BC between March 1995 and March 1998.

RESULTS

The final analysis assessed the data relating to 529 patients who underwent axillary dissection. Pain was reported by 39.7% of women with higher incidence in patients who underwent CS than in those who underwent MRM +/- IBR, but this difference did not reach statistical significance (p = 0.07). The only statistically significant difference (p < 0.05) between the surgical groups was the pain appearance that occurred earlier in the CS patients and later in the MRM + IBR patients. No other differences were observed. The women with pain had significantly worse QL scores on all of the subscales than those without.

CONCLUSION

Pain after surgery for BC distress almost one-third of patients, regardless of the type of treatment, and had a negative effect on patients' QL. The different surgical procedures may marginally influence the quantitative characteristics of pain.

Lymphedema in women treated for breast cancer

OBJECTIVES

To review the clinical and evidence-based knowledge of lymphedema in women treated for breast cancer, including the anatomy, physiology, pathophysiology, diagnosis, management, and nursing role.

DATA SOURCES

Research studies, review articles, clinical literature, American Cancer Society lymphedema work group proceedings.

CONCLUSIONS

Arm lymphedema can be a consequence of treatment for breast cancer and may affect all aspects of quality of life at any time during recovery and long-term survivorship. Prevention and early treatment are vital.

IMPLICATIONS FOR NURSING PRACTICE

As patient advocates, nurses can document patient complaints, conduct arm assessments, and reinforce arm precautions at every clinical visit. Knowledge of research and treatment advances is crucial to enhancing the quality of life of women treated for breast cancer.

Menopause as an issue for women with breast cancer

Menopause is beginning to be recognized as a survivorship issue for women with a diagnosis of breast cancer. This article presents an outline of the literature relating to natural menopause and its symptoms, moves on to discuss general management of menopausal symptoms, then reflects on the particular implications of breast cancer diagnosis and treatment. Finally, the role of nursing in restoring a holistic perspective to the subject of menopause generally, and to women with breast cancer specifically, is considered.

Chronic post-treatment symptoms in patients with breast cancer operated in different surgical units

AIMS

This study was designed to find out whether women operated in high volume surgical units have less chronic symptoms than women operated in smaller volume units.

METHODS

A questionnaire was sent to 265 consecutive women treated at the Department of Oncology, Helsinki University Central Hospital, from January to June 1996. Of the patients, 129 were operated in hospitals experienced in breast cancer surgery (high volume units = HVU) and 92 patients in district hospitals with less experience in breast surgery (low volume units = LVU).

RESULTS

Chronic symptoms were less common in HVU than in LVU: chronic pain (56 vs. 43%, P<0.05) or strange sensations (45 vs. 26%, P<0.01) in the ipsilateral arm or phantom sensations in the removed breast (66 vs. 26%, P<0.001). The risk factors included in the multivariate model for chronic pain in the breast area were: intensity of acute post-operative pain, radiotherapy and depression and for the chronic arm pain: low volume unit and depression.

CONCLUSIONS

More careful surgical technique seems to reduce the risk of chronic pain following treatment of breast cancer. Chronic pain is associated with more intense post-operative pain and depression.

Pain and other symptoms during the first year after radical and conservative surgery for breast cancer

This study assessed pain, neurological symptoms, oedema of the ipsilateral arm, anxiety and depression occurring in women treated surgically for breast cancer, the impact of these symptoms on daily life and how they evolved during the 1 year follow-up. Ninety-three consecutive patients with non-metastasised breast cancer who were treated during 1993-94 were examined before surgery and after 1, 6 and 12 months. They were asked about pain, neurological symptoms and oedema in the breast scar region and/or ipsilateral arm. Sensory testing was performed, and gripping force and the circumference of the arm were measured. Anxiety and depression were evaluated. One year after surgery, 80% of the women had treatment-related symptoms in the breast scar region and virtually all patients had symptoms in the ipsilateral arm. The incidence of chronic post-treatment pain was higher after conservative surgery than after radical surgery (breast area: 33% vs 17%, NS; ipsilateral arm: 23% vs 13%, NS). Numbness occurred in 75% and oedema of the ipsilateral arm in over 30% of the patients after both radical and conservative surgery. Phantom sensations in the breast were reported by 25% of the patients. No difference in psychic morbidity was detected after the two types of surgery. Both the anxiety and depression scores were highest before surgery, decreasing with time, and were significantly correlated with preoperative stressful events.

Postmastectomy pain syndromes

Pain associated with cancer and its treatment continues to be a significant concern for those persons diagnosed with the illness. This article will focus on pain syndromes associated with surgical interventions for women with breast cancer. Postmastectomy pain syndromes including postaxillary dissection pain and phantom breast pain will be described in terms of their nature, incidence, and temporal course based on current literature findings. Treatment strategies and implications for nursing interventions employed in caring for these women will also be discussed. Nurses can use information about postmastectomy pain syndromes to educate their patients, to cooperate in successfully managing effects of the disease and treatment, and to help women cope after breast cancer surgery.

Pain and other symptoms after different treatment modalities of breast cancer

PURPOSE

The aim of this study was to analyse the risk factors that predispose women to chronic symptoms related to the treatment of breast cancer.

PATIENTS AND METHODS

A questionnaire was sent to 569 women who had undergone modified radical mastectomies with axillary evacuation (MRM) or breast resection with axillary evacuation (BCT).

RESULTS

Pain, paraesthesias and strange sensations were reported by half of the patients. The chronic pain slightly affected the daily lives of about 50% of the patients and moderately or more the daily lives of about 25% of the patients. Pain was reported significantly more often after BCT than after MRM both in the breast scar (BS) and in the ipsilateral arm (IA). The patients with chronic pain were significantly younger and had larger primary tumours. Postoperative complications increased the incidence of chronic pain in the IA. The highest incidence of pain in the IA was reported by patients who had had both radio- and chemotherapy. The fact that the incidence of pain (IA) had a significant correlation with the incidence of paraesthesias, oedema, strange sensations and muscle weakness may be an indication of nerve injury.

CONCLUSIONS

Chronic pain was more common after breast-conserving surgery than after radical surgery. Surgical complications and postoperative radiotherapy and chemotherapy increased the risk of chronic pain and other symptoms. Modifications in the treatment protocol and preclusion of postoperative complications may be necessary in order to minimize chronic treatment-related symptoms.

Symptoms and rehabilitation needs of patients with early stage breast cancer during primary therapy

The treatment for women diagnosed with early breast cancer is complex, dynamic, and controversial. More choices are available for local control and indications for systemic adjuvant therapy have changed dramatically. Knowledge of predictable physical and psychological responses through the various phases of primary treatment is the first critical element for the rehabilitation of these oncology patients. The health care provider can then anticipate problems, prepare the patient with accurate information, and institute interventions early to minimize symptoms. Information and psychological needs dominate the diagnostic phase, during which communication and emotional support are of paramount importance for decision making. Psychological distress persists through the treatment phase regardless of the choice of mastectomy or breast conservation surgery with radiation. The physical symptoms of these choices are similar, primarily related to the axillary lymph node dissection. Fatigue, breast soreness, sensation, and skin changes are common symptoms with breast irradiation that resolve over time. Nausea, vomiting, fatigue, hair loss, menopausal symptoms, and weight gain are predictable chemotherapy-related side effects and are reported as mild to moderately distressful by the majority of patients. Consistency of information, support, collaboration, coordination of care, and communication among patients and health care providers are essential to meet the challenge of successful treatment and rehabilitation.

Breast appearance and function after breast conserving surgery and radiotherapy

Between 1978 and 1985, 247 breast cancer patients were treated with breast conserving surgery and radiotherapy. One hundred and twenty of these patients form the basis of this report, having replied to an 11-point structured questionnaire evaluating breast appearance and breast, shoulder and arm function. Good to perfect cosmetic, functional and overall scores are shown to be in the range 61-89%. The extent of primary surgery and axillary irradiation are the major factors affecting the cosmetic appearance. Other problems with cosmetic and functional assessment from subjective and objective view points are also discussed.

Early breast cancer. A review

The therapy of early breast cancer has been changing during the last decennium. It requires a multi-disciplinary approach and in each of these disciplines improvements have been implemented. The result is that treatment schedules can now be adapted to specific subgroups. In this review early breast cancer is defined as operable disease, using the critera set out by Haagensen. Emphasis is given to describing the new developments in prognostic criteria, since these form the basis for creating subgroups for specific treatment schedules. Distinction is made between the factors relating to growth rate and those relating to metastatic potential. Data on screening promises a beneficial effect of the implementation of screening in national health care programs. Important shifts are seen in treatment schedules; the place of postoperative radiotherapy after classic ablative treatment is being challenged, whereas it plays a major role in the new breast conserving therapy schedules. The data mentioned in the review suggest that a large proportion of 'operable' cases can be treated with breast conservation but details in the technique of breast conserving therapy are still under investigation. They form a major part of the coming prospective studies in breast cancer. Improvements in reconstruction techniques, creating better cosmetic results, make reconstruction more competitive with breast conserving therapy. The use of chemotherapy and endocrine manipulation in early breast cancer has now been clearly confirmed by the overview technique by the Peto-group, thanks to all efforts of individual trialists together.